Corrective Action Plans

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Finding 2023-003 – Filing with the State Auditor and Federal Audit Clearinghouse Condition: The City did not submit its audit report to the State Auditor prior to the deadline of six months after the end of the fiscal year ending June 30, 2023. Additionally, the City did not submit its audit report ...
Finding 2023-003 – Filing with the State Auditor and Federal Audit Clearinghouse Condition: The City did not submit its audit report to the State Auditor prior to the deadline of six months after the end of the fiscal year ending June 30, 2023. Additionally, the City did not submit its audit report to the FAC within nine months from year ending June 30, 2023. In conjunction with our FY2023 single audit, please see the City’s corrective action plan below: Management recognizes the need to submit its single audit reports to the State Auditor and FAC in accordance with the required deadlines in order to remain compliant with the requirements. Management has made Professional Services changes to ensure timely audit compliance moving forward.
The City will work to ensure all reports for grant funding are completed.
The City will work to ensure all reports for grant funding are completed.
2023-4 –Activities Allowed Contact Person: Kaitlin M. Rosselli, Business Manager Recommendation: We recommend that the District strengthen internal controls over payroll charged to Federal awards by ensuring required approvals are obtained and review processes occur. Additionally, the District shoul...
2023-4 –Activities Allowed Contact Person: Kaitlin M. Rosselli, Business Manager Recommendation: We recommend that the District strengthen internal controls over payroll charged to Federal awards by ensuring required approvals are obtained and review processes occur. Additionally, the District should review their record retention policy to ensure sufficient supporting documentation is retained to demonstrate compliance with Federal requirements. Action: The District will ensure that all payroll timecards are approved and signed by the appropriate supervisor before being processed for payment. The payroll clerk will not process the timecard unless it is signed and approved. Additionally, we will review the District’s record retention policy to ensure sufficient supporting documentation is retained to demonstrate compliance with Federal requirements. The District will thoroughly review timecards to avoid clerical errors in the future. Date for Completion: These steps have already been put into place and will continue to be built upon.
2023-3 –Equipment and Real Property Management Contact Person: Kaitlin M. Rosselli, Business Manager Recommendation: We recommend that the District implement procedures to ensure prior written approval is obtained for applicable equipment purchases funded by federal grants and that fixed asset recor...
2023-3 –Equipment and Real Property Management Contact Person: Kaitlin M. Rosselli, Business Manager Recommendation: We recommend that the District implement procedures to ensure prior written approval is obtained for applicable equipment purchases funded by federal grants and that fixed asset records include all required information in accordance with Uniform Guidance. The District should also provide appropriate training to personnel involved in grant purchasing and asset management to ensure ongoing compliance. Action: ARP-ESSER III was the first time the District purchased equipment over the $5,000 threshold with federal funding, so processes and procedures for doing so were not in place at the time of the purchases. In the future, the District will implement procedures to ensure written approval is obtained for applicable equipment purchases funded by federal grants prior to purchasing. We will also provide appropriate training to personnel involved in grant purchasing and asset management to ensure ongoing compliance. Date for Completion: These steps have already been put into place and will continue to be built upon.
The City will design and implement controls to ensure that federal awards are expended only for allowable activities.
The City will design and implement controls to ensure that federal awards are expended only for allowable activities.
Response to finding 2023-003 – Lack of Documented Approval for Payroll Transactions Views of Responsible Officials: CSforALL management agrees with the conditions identified by SAX Advisory Group, including the noted causes and resulting effects under 2023-003. Due to the organizational pause at the...
Response to finding 2023-003 – Lack of Documented Approval for Payroll Transactions Views of Responsible Officials: CSforALL management agrees with the conditions identified by SAX Advisory Group, including the noted causes and resulting effects under 2023-003. Due to the organizational pause at the end of 2024 and the transition period throughout 2025, the Organization discontinued its prior payroll system when staff were laid off and shifted remaining personnel to contractor status. During this period, approval and payment of contractor invoices were processed through Ramp, with documentation maintained but not within a formalized payroll approval workflow. As CSforALL prepares for the 2026 rebuilding phase, management has re-established a structured payroll approval and documentation process aligned with audit recommendations. Corrective Action taken in 2025: Beginning in August 2025, the Organization transitioned to ADP, a trusted payroll service integrated with QuickBooks, in anticipation of restoring full payroll operations in 2026. Since implementation, payroll reporting and documentation have been maintained accurately each month by the Operations Manager and the Accountant, with formal approval granted by the Advisory Consultant. All invoices, payments, and payroll records are shared and stored bi-weekly as payroll is executed, establishing a consistent and documented approval trail. Corrective Action Planned for 2026: Beginning in January 2026, CSforALL will apply standardized supervisory approval procedures within ADP for all payroll transactions. Management will implement periodic monitoring of payroll records, ensure consistent use of the approved timekeeping and approval system, and maintain documentation of all supervisory approvals to ensure compliance with established internal controls throughout the 2026 operating year and beyond.
Finding 2023-003 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June ...
Finding 2023-003 Name of Contact Person: Debra Hansen, Finance Project Manager – Grants and Gifts Corrective Action Plan: Effective January 1, 2025, MCHS, Inc was acquired by Sanford Health. MCHS grants accounting and grants management staff joined the Sanford Health’s Office of Grants team by June 2025 and have been trained and have fully implemented Sanford Health procedures by September 2025, such that the Sanford Health system of controls now extend to MCHS. Specifically with these changes, grants management and accounting duties have also transitioned to the MCHS grant team which extends Sanford Health’s systems of control to MCHS to ensure accurate and timely completion of the Schedule. Completion Date: September 30, 2025.
Finding 2023-002 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and docum...
Finding 2023-002 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: Management concurs with the recommendation and will collaborate with Travel Department and other Administrative staff to strengthen controls and implement supervisory review and documented approval of employee reimbursed expenditures charged to externally sponsored programs. It can be noted that, subsequent to sample testing, the one transaction in question was reviewed by Management and deemed an allowable cost.Completion Date: December 31, 2024
Finding 2023-001 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: In December 2022, changes were made to the MCHS lab ordering process and a new report was created to track employee COVID test results. This report reflected two rows of information f...
Finding 2023-001 Name of Contact Person: Debra Hansen, Accounting Manager – Grants and Gifts Corrective Action Plan: In December 2022, changes were made to the MCHS lab ordering process and a new report was created to track employee COVID test results. This report reflected two rows of information for each individual employee tested. One for the test order and a second for the test result. Each row was counted and costed as two separate employee tests and therefore a portion of the cost for employee COVID tests was accidentally doubled and overstated in the portal for Period 5. However, although these expenses were overstated by $49,000, the grant was not overcharged as these questioned costs would be fully replaceable by an allowable amount of unused eligible lost revenues of approximately $109,516,000. Management will implement a procedure that requires a second level review of expenditures reported to ensure accuracy of reimbursement claimed for federal- and state-funded expenditures.Completion Date: September 30, 2024
PUC concurs with the auditor's recommendation. PUC will access its' needs for additional personnel and resources. October 2025, Daisy Nanpei, CFO
PUC concurs with the auditor's recommendation. PUC will access its' needs for additional personnel and resources. October 2025, Daisy Nanpei, CFO
Finding 1167725 (2023-010)
Material Weakness 2023
We agree with the recommendations offered for the relevant programs and will establish and implement policies that provide for documentary evidence of review of applicable reports by qualified individuals to ensure the timely submission of required reports to applicable federal agencies that can be ...
We agree with the recommendations offered for the relevant programs and will establish and implement policies that provide for documentary evidence of review of applicable reports by qualified individuals to ensure the timely submission of required reports to applicable federal agencies that can be easily reconciled to the underlying accounting records.
Finding type: Significant deficiency.
Finding type: Significant deficiency.
Federal award: 93.912, Rural Health Care Services Outreach.
Federal award: 93.912, Rural Health Care Services Outreach.
Passthrough organization: Not applicable.
Passthrough organization: Not applicable.
Condition: Lack of approval on bank reconciliations and journal entries.
Condition: Lack of approval on bank reconciliations and journal entries.
Management concurrence: Management concurs with this finding.
Management concurrence: Management concurs with this finding.
Corrective action plan: VAMHAR has put internal controls and a process in place for approvals of journal entries reconciliations as of fiscal year 2024.
Corrective action plan: VAMHAR has put internal controls and a process in place for approvals of journal entries reconciliations as of fiscal year 2024.
Name of contact person: Daniel Franklin, Executive Director and Lisa Lord, Director of Operations.
Name of contact person: Daniel Franklin, Executive Director and Lisa Lord, Director of Operations.
Projected completion date: December 31, 2025.
Projected completion date: December 31, 2025.
Federal award: 93.912, Rural Health Care Services Outreach.
Federal award: 93.912, Rural Health Care Services Outreach.
Condition: Incomplete procurement policies and procedures.
Condition: Incomplete procurement policies and procedures.
Management concurrence: Management concurs with this finding.
Management concurrence: Management concurs with this finding.
Corrective action plan: VAMHAR is updating the Organization’s procurement policy and internal controls to comply with the Uniform Guidance standards.
Corrective action plan: VAMHAR is updating the Organization’s procurement policy and internal controls to comply with the Uniform Guidance standards.
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